Spirometry use among pediatric primary care physicians

Childhood Asthma Control Test and spirometry values in school-age children

OBJECTIVE

To determine the relationship between child and parent reports of asthma control using the Childhood Asthma Control Test (C-ACT) and spirometry.

METHODS

This descriptive study included 648 children ages 5-11 years from a school-based asthma program. Not well-controlled asthma was defined as forced expiratory volume in 1 s (FEV1) and by FEV1/forced vital capacity (FVC) of 80% predicted or lower. Sensitivity and specificity of C-ACT scores for low FEV1 and FEV1/FVC levels were calculated. Logistic regression was used to obtain the area under the receiver operating characteristic curve (AUC) for C-ACT score categories by FEV1 level.

RESULTS

Mean child age was 8.2 years, mean C-ACT score was 20.3 (SD = 3.96), mean FEV1 was 94.3% (SD = 17.1), and mean FEV1/FVC was 81.3 (SD = 8.5). Children with an FEV1 of 80% or less had significantly lower C-ACT scores than those with an FEV1 > 80% (p = .023, t = -2.015, df = 167); 95% CI [. -1.79 to -0.018]). The sensitivity and specificity of a C-ACT score of 19 or less for an FEV1 of 80% predicted or lower were 44.9 and 66.4%. With a C-ACT score of 22 or less, sensitivity and specificity for low FEV1 were 67.7 and 30.9%. The AUC for a C-ACT score of 19 or less and FEV1 of 80% or lower was .444 while the AUC was higher at .507 for a CACT score of 22 or less.

CONCLUSION

The C-ACT is a useful screen but spirometry should be performed in children with persistent symptoms to assess current asthma control.

MICROS: Asthma Control App for School Adolescents in a Low Resource Setting - A Cluster Randomized Controlled Trial Protocol

Introduction

Poor asthma control in adolescents is partly attributed to inadequate asthma education for self-management. This study is set to determine the effectiveness of the "KmAsthma" self-management app in improving the control of asthma among adolescents in a low-resource setting.

Methods

The two-arm 6-month cluster randomized controlled trial, will aim at enrolling 120 day scholars aged 12-19 years in secondary schools with a clinician's diagnosis and self-reported uncontrolled asthma in Kampala City Uganda. The primary endpoint of asthma control will be measured as a change in mean Asthma Control Test (ACT) scores. Asthma quality of life, adherence to medications, and self-efficacy will also be assessed. The iMprovIng the ContROl of aSthma (MICROS) study will employ the "KmAsthma" app for self-management education. The intervention group will receive the app on their smartphones and training on its eight sections: the profile, asthma history, goals, inspirations, reminders, connect, information about asthma, and emergency support. Participants will navigate these sections to set asthma control goals, schedule medication reminders, log daily symptoms, and receive guidance for attacks. All participants will be encouraged to seek routine care. A study nurse will follow up with each participant via the phone six weeks post-intervention. The MICROS study was approved by the Makerere University School of Medicine Research and Ethics Committee and the Uganda National Council of Science and Technology. This protocol is registered on Clinicaltrials.gov (NCT05850806).

Conclusion

The MICROS study will provide comprehensive insights into how effective a mHealth intervention can be an aid for adolescents in a low-resource setting in managing their asthma. The findings of this study will contribute to filling the gap leading to unsatisfactory asthma control in adolescents.

Obesity-related pediatric asthma: relationships between pulmonary function and clinical outcomes

OBJECTIVE

We hypothesized that children with obesity-related asthma would have worse self-reported asthma control, report an increased number of asthma symptoms and have lower FEV1/FVC associated with worse clinical asthma outcomes compared to children with asthma only.

METHODS

Cross sectional analyses examined two hundred and eighteen (obesity-related asthma = 109, asthma only = 109) children, ages 7-15 that were recruited from clinics and hospitals within the Bronx, NY. Pulmonary function was assessed by forced expiratory volume in the first second (percent predicted FEV1) and the ratio of FEV1 to the forced vital capacity of the lungs (FEV1/FVC). Structural equation modeling examined if pulmonary function was associated with asthma control and clinical outcomes between groups.

RESULTS

Lower percent predicted FEV1 was associated with increased hospitalizations (p = 0.03) and oral steroid bursts in the past 12 months (p = 0.03) in the obesity-related asthma group but not in the asthma only group. FEV1/FVC was also associated with increased hospitalizations (p = 0.02) and oral steroid bursts (p = 0.008) in the obesity-related asthma group but not the asthma only group. Lower FEV1/FVC was associated with the number of asthma symptoms endorsed in the asthma only group but not in the obesity-related asthma group. Percent predicted FEV1 and FEV1/FVC was not associated with asthma control in either group.

CONCLUSIONS

Pulmonary function was associated with oral steroid bursts and hospitalizations but not self-reported asthma control, suggesting the importance of incorporating measures of pulmonary function into the treatment of pediatric obesity-related asthma.

Does routine spirometry impact on clinical decisions and patient-related outcome measures of children seen in respiratory clinics: an open-label randomised controlled trial

INTRODUCTION

There is limited evidence on the efficacy of using spirometry routinely in paediatric practice for improving outcomes.

OBJECTIVE

To determine whether the routine use of spirometry alters clinical decisions and patient-related outcome measures for children managed by respiratory paediatricians.

METHODS

We undertook a parallel open-label randomised controlled trial involving children (aged 4-18 years) able to perform spirometry in a specialist children's hospital in Australia. Children were randomised to either routine use of spirometry (intervention) or clinical review without use of spirometry (control) for one clinic visit. The primary outcomes were the (a) proportion of children with 'any change in clinical decisions' and (b) 'change score' in clinical decisions. Secondary outcomes were change in patient-related outcome measures assessed by State-Trait Anxiety Inventory (STAI) and Parent-Proxy QoL questionnaire for paediatric chronic cough (PC-QoL).

RESULTS

Of 136 eligible children, 106 were randomised. Compared with controls, the intervention group had significantly higher proportion of children with 'any change in clinical decisions' (n=54/54 (100%) vs n=34/52 (65.4%), p<0.001) and higher clinical decision 'change score' (median=2 (IQR 1-4) vs 1 (0-2), p<0.001). Also, improvement was significantly greater in the intervention group for overall STAI score (median=-5 (IQR -10 to -2) vs -2.5 (-8.5, 0), p=0.021) and PC-QoL social domain (median=3 (IQR 0 to 5) vs 0 (-1, 1), p=0.017).

CONCLUSION

The routine use of spirometry in children evaluated for respiratory issues at clinical outpatient review is beneficial for optimising clinical management and improving parent psychosocial well-being.

REGISTRATION

Australia and New Zealand Clinical Trials Registry ACTRN12619001686190.

An assessment of the predictive value of low risk criteria for children with intermittent asthma

BACKGROUND

Current asthma guidelines recommend short acting beta agonist medication (SABA) be used in combination with an inhaled corticosteroid to reduce risk for severe asthma exacerbations. This may not be appropriate for patients at low risk for severe exacerbations.

METHODS

This study is a cohort study using computerized claims data from Texas Children's Health Plan. Inclusion criteria were members 1 to <18 years with a diagnosis of asthma in a baseline year between 2016 and 2018 and who had ≤2 SABA canisters or equivalent dispensed, no oral corticosteroid or inhaled corticosteroid dispensing, no asthma hospitalizations, and no asthma emergency department visits in the baseline year. Follow up year outcomes of asthma hospitalizations and emergency department visits were determined for the year following the baseline year.

FINDINGS

Forty-five thousand two hundred and thiry health plan members 1 to <18 years met inclusion criteria. The rate of follow up year asthma hospitalization was 1.1 per thousand for those with no baseline SABA dispensing and 1.5 per thousand for those with >0 and ≤2 SABA canister dispensings (p = 0.3). Follow up year Emergency Department visits rates were 14 per thousand and 17 per thousand, respectively (p = 0.08). In analyses adjusted for age group, the follow up year asthma hospitalization rate was not different comparing the 0 SABA to the >0 and ≤2 SABA canister dispensings group (odds ratio: 0.99, 95% confidence interval: 0.54-1.81).

INTERPRETATION

Asthma patients at low risk for severe exacerbations can be identified. This information can be useful to guide treatment decisions.

Correlation of digital flow peak with spirometry in children with and without asthma

INTRODUCTION

Spirometry and peak expiratory flow measurement (PEF) are combined during functional respiratory assessments. The new digital peak flow meter (DPM) evaluates the forced expiratory volume in the first second (FEV₁) and PEF.

OBJECTIVE

To compare lung function measurements using spirometry and DPM.

METHODS

This cross-sectional analytical study assessed FEV₁ and PEF in children with and without asthma. Statistical analysis was performed to assess the agreement between the measures using the intraclass correlation coefficient (ICC), Bland-Altman, and survival agreement plot.

RESULTS

125 (3-12 y) and 196 (6-18 y) children without and with asthma, respectively, were studied. In children without asthma, the ICC for FEV₁ and PEF were 0.89 and 0.86, respectively, while the corresponding values were 0.87 and 0.79, respectively, in patients with asthma. The Bland-Altman method showed a difference of -0.4 to 0.5 for FEV₁ in patients without asthma, with a tendency to increase as the FEV₁ increased to a certain extent. In patients with asthma, the pattern was similar for FEV₁, and the PEF had a greater dispersion than among those without asthma; however, a good agreement pattern was maintained. In the survival agreement plot, when accepting a tolerance of 0.150 mL for FEV₁, there was an agreement of close to 55% in both groups. Likewise, when accepting a tolerance of 0.5 L/s for PEF, an agreement of close to 60% and 50% was observed in patients without and with asthma, respectively.

CONCLUSION

DPM was effective as a measure of lung function in pediatric patients with and without asthma.

Does the routine use of spirometry improve clinical outcomes in children?-A systematic review

Spirometry provides a quantitative measure of lung function and its use is recommended as an adjunct to enhance pediatric respiratory healthcare in many clinical practice guidelines. However, there is limited evidence confirming the benefits (or otherwise) of using spirometry from either clinician or patient perspectives. This systematic review aimed to determine the impact of spirometry on change in clinical decision making and patient-reported outcome measures. We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, www.clinicaltrials.gov, and World Health Organization International Clinical Trials Registry Platform, from inception to July 2021. We included randomized controlled trials (RCTs) comparing the use versus non-use of spirometry during standard clinical review in children aged <18 years with respiratory problems in clinics. We used Cochrane methodology. The search identified 3475 articles; 8 full-text articles were reviewed but only 1 study fulfilled the inclusion criteria. The single study involved two cluster RCTs of spirometry for children with asthma in general practice. The included study did not find any significant intergroup difference at the 12-month follow-up for asthma-related quality-of-life and clinical endpoints. However, the findings were limited by methodological weaknesses and high risks of bias. With a paucity of data, the clinical benefits of spirometry remain unclear. Thus, there is a clear need for RCTs that provide high-quality evidence to support the routine use of spirometry in children with suspected or known lung disease. Pending the availability of better evidence, we recommend that clinicians adhere to the current clinical practice recommendations.

Reference values for respiratory sinusoidal oscillometry in children aged 3 to 17 years

BACKGROUND

New oscillometry devices allowing quantification of respiratory function using tidal breathing are commercially available, but reference equations are lacking for the multiethnic Canadian pediatric population.

METHODS

We conducted a prospective cross-sectional study of healthy children carefully selected for absence of asthma, atopy, tobacco smoke, obesity, prematurity, and recent respiratory infection. Triplicate measures were obtained of respiratory system resistance (Rrs) and reactance (Xrs), area under the reactance curve (AX) and resonant frequency (Fres) on four signals, whose testing order was randomized: two signals on the Resmon Pro Full (8 Hz and 5-11-19 Hz) and two signals on the tremoflo C-100 (5-37 Hz and 7-41 Hz). Feasibility was defined as the ability to obtain valid reproducible results. Prediction equations and 95% confidence intervals were derived for whole- and within-breath Rrs and Xrs and for AX and Fres, using linear regression or Generalized Additive Models for Location, Scale and Shape.

RESULTS

Of 306 children randomized, valid and reproducible results on ≥1 signal were obtained in 299 (98%) multiethnic (69% Caucasians: 8% Black: 23% Others) children aged 3-17 years, 91-189 cm tall. Standing height was the strongest predictor with no significant effect of sex, age, body mass index or ethnicity. Significant within-patient differences were observed between Resmon Pro and tremoflo C-100 measurements, justifying the derivation of device-specific reference equations.

CONCLUSION

Valid reproducible oscillometry measurements are highly feasible in children aged 3 years and older. Device-specific reference equations, valid for our multiethnic population, are derived.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework

BACKGROUND

Although guidelines have long recommended objective pulmonary function testing to diagnose asthma and chronic obstructive lung disease (COPD), many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. This often leads to unnecessary treatment with associated incremental costs and side-effects, and delays actual diagnosis.

RESEARCH QUESTION

What are the barriers and enablers to lung function testing for asthma and/or COPD in primary care?

STUDY DESIGN AND METHODS

We searched the literature for qualitative and quantitative studies reporting barriers and/or enablers to in-office or out-of-office lung function testing for diagnosing asthma and/or COPD, in primary care. Two reviewers independently screened abstracts and full texts; assessed methodological quality using the Mixed Methods Appraisal Tool; and extracted data from included studies. Identified barriers and enablers were categorized using the Theoretical Domains Framework (TDF), applying a pre-established coding manual.

RESULTS

We identified 7988 unique articles, reviewed 336 full-text articles, and included 18 studies in this systematic review. Of these 18, 12 were quantitative, 3 were qualitative, and 3 used mixed methods. All 18 addressed in-office testing and 11 also addressed out-of-office testing. Barriers and enablers overlapped for asthma and COPD, and in- and out-of-office settings. We identified more reported barriers (e.g. lack of knowledge of the usefulness of spirometry) than enablers (e.g. skills for performing reliable spirometry). Barriers mapped to 9 (of a possible 14) TDF domains (for both in- and out-of-office settings). Enablers mapped to three domains for in-office testing and five domains for out-of-office testing.

INTERPRETATION

Barriers to objective testing for airways disease in primary care are complex and span many theoretical domains. Correspondingly, a successful intervention must leverage multiple behaviour change techniques. A theory-based, multifaceted intervention to address underuse of diagnostic testing for asthma or COPD should now be developed and tested.

Impact of using spirometry on clinical decision making and quality of life in children: protocol for a single centre randomised controlled trial

INTRODUCTION

Although spirometry has been available for decades, it is underused in paediatric practice, other than in specialist clinics. This is unsurprising as there is limited evidence on the benefit of routine spirometry in improving clinical decision making and/or outcomes for children. We hypothesised that using spirometry for children being evaluated for respiratory diseases impacts on clinical decision making and/or improves patient-related outcome measures (PROMs) and/or quality of life (QoL), compared with not using spirometry.

METHODS AND ANALYSIS

We are undertaking a randomised controlled trial (commenced in March 2020) that will include 106 children (aged 4-18 years) recruited from respiratory clinics at Queensland Children's Hospital, Australia. Inclusion criteria are able to perform reliable spirometry and a parent/guardian who can complete questionnaire(s). Children (1:1 allocation) are randomised to clinical medical review with spirometry (intervention group) or without spirometry (control group) within strata of consultation status (new/review), and cough condition (present/absent). The primary outcome is change in clinical decision making. The secondary outcomes are change in PROM scores, opinions regarding spirometry and degree of diagnosis certainty. Intergroup differences of these outcomes will be determined by χ2 test or unpaired t-test (or Mann-Whitney if not normally distributed). Change in outcomes within the control group after review of spirometry will also be assessed by McNemar's test or paired t-test/Wilcoxon signed-rank test.

ETHICS AND DISSEMINATION

The Human Research Ethics Committee of the Queensland Children's Hospital approved the study. The trial results will be disseminated through conference presentations, teaching avenues and publications.

TRIAL REGISTRATION NUMBER

ACTRN12619001686190; Pre-results.

Pharmacist Provided Spirometry Services: A Scoping Review

Purpose

Despite international guidelines' recommendations, spirometry is underutilized in the diagnosis and management of asthma and COPD. Spirometry may be an opportunity for trained pharmacists to meet the needs of patients with suspected or diagnosed lung conditions. The aim of this scoping review is to describe the literature including pharmacist provided spirometry services, specifically to identify: 1) the models of pharmacist provided spirometry services, and additional services commonly offered alongside spirometry, 2) pharmacist training and capability to obtain quality results, and (3) pharmacist, physician, and patient perspectives.

Methods

In September 2020, a comprehensive literature search in PubMed and EMBASE was conducted to identify all relevant literature on the topic of pharmacist provided spirometry services using the search term: "pharmacist or pharmacy" and "spirometry or pulmonary function test or lung function test." Literature was screened using inclusion/exclusion criteria and selected articles were charted and analyzed using the themes above.

Results

A total of 27 records were included. The scoping review found that pharmacist provided spirometry has been conducted around the world in community pharmacies and clinic settings. Community pharmacists may increase access to spirometry screening; the lack of communication with primary care providers and remuneration are barriers that need to be overcome to optimize the utility of the service. Clinic-based services are interprofessional and collaborative, allowing a patient to receive the test, results, diagnosis, and medication changes in one visit. Following comprehensive training, pharmacists felt confident in their ability to perform spirometry and met quality standards at acceptable rates.

Conclusion

Spirometry is an opportunity for pharmacists to improve evidence-based practice for screening and diagnosing lung conditions along with providing comprehensive services to complement testing. Data around provider and patient perspectives is limited and should be further investigated to determine if providers and patients would value and collaborate with pharmacists providing spirometry services.

Spirometry Abnormalities and Its Associated Factors Among Primary School Children in a Nigerian City

BACKGROUND

There is paucity of data on objectively measured lung function abnormalities in Nigerian children using diagnostic testing methods such as spirometry. Such assessments could prompt early diagnosis and therapeutic interventions.

METHODS

This was a cross sectional study among children aged 6 to 12 years in South-Eastern Nigeria. We selected participants from one school using a multistage stratified random sampling technique. A structured respiratory questionnaire was administered to obtain necessary data. The lung functions of the children were measured by spirometry. We used Lower Limits of Normal (LLN) based on GLI reference equations for African-American and mixed ethnicities to define abnormal spirometry. We studied the association between the exposures and lung function using logistic regression/chi-squared tests.

RESULTS

A total of 145 children performed acceptable and repeatable tests. There were 73 males (50.3%), mean age of 9.13 years (+1.5) and age range 6 to 12 years. Frequency of respiratory symptoms was cough- 64 (44.1%) and wheeze in 19 (13.1%). Using GLI for African-Americans, fifty-five (37.9%) children had abnormal spirometryobstructive pattern in 40 (27.6%) and restrictive pattern in 15 (10.3%). The two references showed significant differences in interpretation of abnormality (χ2 = 72.86; P < .001). Respiratory symptom-wheeze was an independent determinant of abnormal lung function in this population.(OR = 0.31; 95%CI: 0.10-0.94; P = .04).

CONCLUSION

There is a high burden of respiratory symptoms and abnormal spirometry among these children. The need for objective evaluation of lung function especially for children with respiratory symptoms is evident.

Comparing lung oscillometry with a novel, portable flow interrupter device to measure lung mechanics

In the community setting, assessing spirometry in school-aged children is often limited by the unavailability of respirology technicians at the point-of-care. We developed a new technique called the Rapid Expiratory Occlusion Method (REOM) that measures respiratory resistance during normal breathing, without specialized training. The aim was to examine the concordance between respiratory resistance measured with the REOM and respiratory resistance measured by oscillometry on the tremoflo. Children aged 6-17 yr, with or without asthma, received respiratory resistance testing on the tremoflo, then on the REOM. Three to five replicates with a coefficient of variation ≤15% were obtained on each instrument; the primary outcome was the concordance between the average respiratory resistance on the REOM and that measured at 5 Hz (R₅) on the tremoflo. Thirty-two children (11 girls; 21 boys) were enrolled with a mean age of 11.2 (range 6-17) yr; after excluding two children not meeting reproducibility criteria, 9 healthy controls, 15 controlled asthmatics, and 6 poorly controlled asthmatics were included. Resistance measured on the REOM showed a strong correlation with R₅ measured on the tremoflo (P < 0.0001) with no significant differences on the Bland-Altman analyses. Children and their parents found the REOM easy to use and would consider for home use if recommended by their doctor. With the high concordance between resistance values measured on the REOM and that on the tremoflo combined with perceived ease of use, the REOM appears as a promising means for measuring lung function, thus supporting further testing of other psychometric properties.NEW & NOTEWORTHY We have developed a novel version of the interrupter technique to measure respiratory resistance. The Rapid Expiratory Occlusion Method (REOM) is a small handheld device that measures respiratory resistance and demonstrates excellent correlation with airway oscillometry. With its ease of use, REOM may be promising for use in community practice, patient's homes, and, if paired with a telemedicine application, could enable the healthcare provider to monitor patients in their homes.

Paediatricians provide higher quality care to children and adolescents in primary care: A systematic review

AIM

The number of primary care paediatricians is decreasing in Europe without a justifiable reason. We aimed to compare the clinical practice of paediatricians and family doctors attending children and adolescents in primary care.

METHODS

MEDLINE, Embase, CENTRAL, TRIP and Google Scholar were searched from December 2008 to February 2018. No language or study design restrictions were applied. Three reviewers assessed eligibility of the studies. Seven pairs of reviewers performed the data extraction and assessed the methodological quality independently. Discrepancies were resolved by consensus.

RESULTS

Fifty-four, out of 1150 studies preselected, were included. We found that paediatricians show more appropriate pharmacology prescription patterns for the illness being treated; they achieve higher vaccination rates and have better knowledge of vaccines and fewer doubts about vaccine safety; their knowledge and implementation of different screening tests are better; they prescribe psychoactive drugs more cautiously and more in line with current practice guidelines; their evaluation and treatment of obesity and lipid disorders follow criteria more consistently with current clinical practice guidelines; and they perform fewer diagnostic test, show a more suitable use of the test and request fewer referrals to specialists.

CONCLUSION

According to published data, in developed countries, paediatricians provide higher quality care to children than family doctors.

Impact of a supervised training course on spirometry competency for primary care pediatricians

Objective: Spirometry is the most commonly performed lung function test, and performance, adherence to acceptability and repeatability criteria, and accurate interpretation of results help optimize the test's usefulness. This study aimed to measure the effects of spirometry training courses supported by the Italian Pediatric Respiratory Society (IPRS) on primary care pediatricians' (PCP) knowledge of spirometry test quality, ability to interpret results, and overall degree of satisfaction with the course.Methods: Of the six face-to-face courses, four lasted two days and two lasted one day: mean duration of theoretical lessons was five and four hours respectively; and practical sessions lasted eight and six hours, respectively. At the end of each course, participants took a learning test consisting of evaluating six flow-volume curves. Degree of satisfaction was assessed by asking participants to rank the relevance, quality, and usefulness of the course.Results: 261 PCPs were involved, with most (67.43%) taking two-day courses. Nearly all participants correctly identified normal and restrictive patterns. Intrathoracic large-airway obstruction was the pattern most difficult to identify correctly (70.5% overall), whereas > 80% of the participants correctly classified artifacts, obstructive-restrictive, and obstructive patterns. Participants in longer courses reported significantly higher values on the learning score. The overall degree of satisfaction average ranged between "good" and "excellent".Conclusions: This pilot study showed the greater impact of two-day courses than one-day courses for training PCPs to properly interpret spirometry, confirming that a practical module lasting at least six hours is sufficient to deliver adequate training on spirometry for healthcare professionals.

An Adolescent With Progressive Shortness of Breath

Shortness of breath and wheezing are common presenting signs for children in the emergency department. In adolescence, it is often due to asthma or lower respiratory tract infections. We present a rare pediatric case of an adolescent with biphasic stridor and progressive exercise-induced shortness of breath who was found to have severe idiopathic subglottic stenosis.

Approaches to the assessment of severe asthma: barriers and strategies

Asthma is a chronic condition with great variability. It is characterized by intermittent episodes of wheeze, cough, chest tightness, dyspnea and backed by variable airflow limitation, airway inflammation and airway hyper-responsiveness. Asthma severity varies uniquely between individuals and may change over time. Stratification of asthma severity is an integral part of asthma management linking appropriate treatment to establish asthma control. Precision assessment of severe asthma is crucial for monitoring the health of people with this disease. The literature suggests multiple factors that impede the assessment of severe asthma, these can be grouped into health care professional, patient and organizational related barriers. These barriers do not exist in isolation but interact and influence one another. Recognition of these barriers is necessary to promote precision in the assessment and management of severe asthma in the era of targeted therapy. In this review, we discuss the current knowledge of the barriers that impede assessment in severe asthma and recommend potential strategies for overcoming these barriers. We highlight the relevance of multidimensional assessment as an ideal approach to the assessment and management of severe asthma.

Reference values for spirometric parameters in healthy children living in a Colombian city located at 2640 m altitude

OBJECTIVES

To identify the spirometric equations that are most appropriate for use in children and adolescents living in Bogota, Colombia after evaluating a set of relevant previously-developed equations, including the Global Lung Function Initiative (GLI) 2012 spirometry reference equations.

METHODS

Healthy children aged between 6 and 17 years that were attending two randomly-selected schools in Bogota were invited to participate in the study, from January 2017 to January 2018. All participants underwent spirometry, following the procedures recommended by the American Thoracic Society/European Respiratory Society (ATS/ERS) Task Force. To identify the model or group of models that best predict each spirometric parameter in our population, we performed extensive residuals analyses and constructed Bland-Altman plots.

RESULTS

Three hundred twenty-six spirometric tests (149 boys, 177 girls) formed the reference data set. Knudson and GLI-2012 spirometry reference equations proved to be the most accurate in predicting the majority of spirometry parameters in both sexes and both age groups, each providing the lowest median prediction error in the residual analyses or the narrowest limits of agreement in the Bland-Altman plots in approximately one-third of the spirometry parameters analyzed.

CONCLUSION

For the majority of spirometry parameters, we recommend the use of Knudson and GLI-2012 spirometry reference equations for evaluating the respiratory function of children living in Bogota, Colombia, a city located at an altitude of 2640 m. Future investigations should target additional spirometric equations from Latin American populations living at moderate to high altitude to improve the GLI-2012 equations.

Diagnosis and management of asthma, COPD and asthma-COPD overlap among primary care physicians and respiratory/allergy specialists: A global survey

INTRODUCTION

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a heterogenous condition with clinical features shared by both asthma and COPD.

OBJECTIVES

This online global survey of respiratory/allergy specialists and primary care practitioners (PCPs) was performed to understand current clinical approaches to the differential diagnosis and management of asthma, COPD and ACO.

METHODS

Respondents were recruited through: (a) a global online physician respondent community (49,980 PCPs and 7205 specialists); (b) market research agents; (c) experts; (d) professional societies; (e) colleague invitation. Respondents were presented with a survey including hypothetical clinical scenarios of diagnostic uncertainty to identify management approaches.

RESULTS

891 responses (447 PCPs and 444 specialists) were collected across 13 countries. Reported features used for diagnosis of asthma and COPD were consistent with practice guidelines, but there was variability in those selected for ACO diagnosis. Features typically selected by specialists focused on spirometry/history, while PCPs focused on previous treatment/symptoms. Most respondents could correctly diagnose patients with features of ACO; however, features selected for theoretical diagnosis were often different to those selected in the case scenarios. Additionally, treatment selection was often inconsistent with guidelines, with over half of respondents not recommending inhaled corticosteroids in a patient with ACO and dominant features of asthma.

CONCLUSION

While most PCPs and respiratory/allergy specialists can reach a working diagnosis of ACO, there remains uncertainty around which diagnostic features are most important and what constitutes optimal management. It is imperative that clinical studies including patients with ACO are initiated, allowing the generation of evidence-based management strategies.

Primary care clinician adherence with asthma guidelines: the National Asthma Survey of Physicians

Background and objectives: Although primary care clinicians provide >60% of U.S. asthma care, no nationally representative study has examined variation in adherence among primary care groups to four cornerstone domains of the Expert Panel Report-3 asthma guidelines: assessment/monitoring, patient education, environmental assessment, and medications. We used the 2012 National Asthma Survey of Physicians: National Ambulatory Medical Care Survey to compare adherence by family/general medicine practitioners (FM/GM), internists, pediatricians and Community Health Center mid-level clinicians (CHC). Methods: Adherence was self-reported (n = 1355 clinicians). Adjusted odds of almost always adhering to each recommendation (≥75% of the time) were estimated controlling for clinician/practice characteristics, and agreement and self-efficacy with guideline recommendations. Results: A higher percentage of pediatricians adhered to most assessment/monitoring recommendations compared to FM/GM and other groups (e.g. 71.6% [SE 4.0] almost always assessed daytime symptoms versus 50.6% [SE 5.1]-51.1% [SE 5.8], t-test p < 0.05) but low percentages from all groups almost always performed spirometry (6.8% [SE 2.0]-16.8% [SE 4.7]). Pediatricians were more likely to provide asthma action/treatment plans than FM/GM and internists. Internists were more likely to assess school/work triggers than pediatricians and CHC (environmental assessment). All groups prescribed inhaled corticosteroids for daily control (84.0% [SE 3.7]-90.7% [SE 2.5]) (medications). In adjusted analyses, pediatric specialty, high self-efficacy and frequent specialist referral were associated with high adherence. Conclusions: Pediatricians were more likely to report high adherence than other clinicians. Self- efficacy and frequent referral were also associated with adherence. Adherence was higher for history-taking recommendations and lower for recommendations involving patient education, equipment and expertise.

Approaches to Asthma Diagnosis in Children and Adults

Although the hallmark features of asthma include reversible airflow obstruction, airway eosinophilia, and symptoms of recurrent wheeze associated with breathlessness and cough, it is a heterogeneous disease. The extent of the pathophysiological abnormalities are variable between patients. Despite this, until recently, asthma diagnosis had been made very simplistically predominantly from a clinical history and examination, and often a trial of medication such as short acting bronchodilators. The limitations of this approach have become increasingly apparent with evidence of inappropriate over diagnosis, under diagnosis and misdiagnosis. Although there is no gold standard single test to make a diagnosis of asthma, there are several objective tests that can be used to support the diagnosis including physiological measures such as obstructive spirometry associated with bronchodilator reversibility and airway hyperresponsiveness. In addition, non-invasive tests of airway inflammation such as exhaled nitric oxide or peripheral blood eosinophils are important to identify those with an allergic or eosinophilic phenotype. Diagnostic guidelines reflect the importance of using objective tests to support a diagnosis of asthma, however practical application in the clinic may not be straightforward. The focus of this review is to discuss the need to undertake objective tests in all patients to support asthma diagnosis and not just rely on clinical features. The advantages, challenges and limitations of performing tests of lung function and airway inflammation in the clinic, the difficulties related to training and interpretation of results will be explored, and the utility and relevance of diagnostic tests will be compared in adults and children.

Implementation of the Asthma Control Test in Primary Care to Improve Patient Outcomes

BACKGROUND

Asthma is one of the major chronic diseases in the pediatric population, affecting 9.5% of children. The National Heart, Lung, and Blood Institute recommends the use of the Asthma Control Test (ACT) for periodic assessment of asthma control. The purpose of this evidence-based project was to implement the Asthma Control Test screening tool into the primary care practice to improve management of patients with asthma by more accurately addressing asthma control.

METHODS

The project was a pre- and post-implementation study comparing two different groups of patients with asthma seen at the clinic over 5-week periods.

RESULTS

After the implementation of the educational program and project, 82.6% of advanced practice registered nurses and 30.7% of pediatric resident physicians used an Asthma Control Test, resulting in identification of 9 (21%) patients who were considered not well-controlled. All (100%) of those children identified as not well-controlled through the Asthma Control Test received an adjustment in their medication therapy.

CONCLUSIONS

The Childhood ACT and ACT are simple, self-administered, validated questionnaires that can easily be incorporated into a primary care practice to assess the level of asthma control and to identify patients with asthma that is not well controlled.

Comparing Asthma Control Questionnaire (ACQ) and National Asthma Education and Prevention Program (NAEPP) asthma control criteria

BACKGROUND

Adequate assessment of control is critical to asthma management. The Asthma Control Questionnaire (ACQ) and the National Asthma Education and Prevention Program (NAEPP) criteria are commonly used measures of asthma control.

OBJECTIVE

To examine the associations between the ACQ and NAEPP criteria and compare the validity in association with lung function, asthma exacerbation, and quality of life.

METHODS

The ACQ and the NAEPP criteria were administered to 373 adolescents with asthma aged 12 to 20 years. The 2 measures correlated with forced expiratory volume in 1 second (FEV₁), asthma exacerbation (oral corticosteroid use, hospitalization, and emergency department [ED] use) in the past 12 months, and quality of life.

RESULTS

Agreement between the ACQ and NAEPP criteria was moderate (κ = 0.40-0.61). Neither of the 2 measures was a reliable predictor of FEV₁ less than 80% because of the high rate of false-positive results for the ACQ (68%) and low sensitivity for the NAEPP (49%). The NAEPP identified more cases of uncontrolled asthma (84.6%) than the ACQ (64.6%). The ACQ was a significant predictor of recent oral corticosteroid use, hospitalization, and ED visits (area under the curve = 0.66, 0.66, and 0.64, respectively; P < .001), as was NAEPP (area under the curve = 0.63, 0.66, and 0.61, respectively; P < .001). Both measures were significantly associated with quality of life, and the associations were particularly strong for the ACQ (r = -0.87 for symptom subscale, r = -0.76 for activity subscale, and r = -0.78 for emotional function subscale).

CONCLUSION

Neither the ACQ nor the NAEPP appears to reliably predict lung function, whereas both measures reasonably associate with acute asthma exacerbation. The ACQ may be the superior measure in gauging the psychosocial effect of asthma control given its particularly strong associations with quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02293499.

Impact of a Pharmacist-Provided Spirometry Service on Access to Results in a Primary Care Setting

OBJECTIVES

The primary objective of this study was to determine the effect of a pharmacist-provided spirometry service within a federally qualified health center on the percentage of spirometry referrals completed with results reviewed by the ordering provider. Secondary objectives evaluated differences between internal and external referrals, medication recommendations made by the pharmacist, and revenue brought in by the service.

METHODS

Chart reviews were completed to determine the referral completion rates between patients who received a spirometry referral before (December 2014-September 2015) and after (January 2016-October 2016) the implementation of the pharmacy-provided spirometry service. Chart reviews were also used to determine the number and completion rate among referrals for internal and external services in the postimplementation time frame. Chart reviews also assessed medication recommendations made by the pharmacist.

RESULTS

The results demonstrate an increase in referral completion rate from 38.1% to 47.0% ( P = .08) between the pre- and postimplementation time frames. In the postimplementation time frame, there was a statistically significant difference in the percentage of referrals completed between in-house referrals and external referrals (70.0% and 40.9%, respectively, P = .0004). Comparing clinics with and without the spirometry service, there was a statistically significant difference in the total number of spirometry referrals (1.13% and 0.59%, respectively, P < .0001) and the percent of referrals completed (0.55% and 0.27%, respectively, P = .0002).

CONCLUSION

The results suggest that offering spirometry within the primary care setting helps to increase the rate of completed spirometry tests with results available to the primary care provider. Additionally, the results show that there is an increased completion rate in patients who receive an internal spirometry referral, which may be due to reduced barriers in obtaining this testing. Overall, these results demonstrate that providing spirometry in the primary care setting helps to increase spirometry results obtained and could be beneficial in other primary care settings.

Reducing emergency department visits utilizing a primary care asthma specialty clinic in a high-risk patient population

OBJECTIVE

Asthma is a leading cause of pediatric emergency department (ED) use. Optimizing asthma outcomes is a goal of Nationwide Children's Hospital (NCH) and its affiliated Accountable Care Organization. NCH's Primary Care Network, comprised of 12 offices serving a predominantly Medicaid population, sought to determine whether an Asthma Specialty Clinic (ASC) operated within a single primary care office could reduce ED asthma rates and improve quality measures, relative to all other network offices.

METHODS

An ASC was piloted with four components: patient monitoring, provider continuity, standardized assessment, and multi-disciplinary education. A registry was established to contact patients at recommended intervals. At extended-length visits, a general pediatrician evaluated patients and a multi-disciplinary team provided education. Novel educational tools were utilized, guideline-based templates recorded and spirometry obtained. ED asthma rate, spirometry utilization, and controller fills by intervention office patients were compared to all other network offices before and after ASC initiation.

RESULTS

At baseline, asthma ED visits by intervention and usual care populations were similar (p = 0.43). After, rates were significantly lower for intervention office patients versus usual care office patients (p < 0.001), declining in the intervention population by 26.2%, 25.2%, and 31.8% in 2013, 2014, and 2015, respectively, from 2012 baseline, versus increases of 3.8%, 16.2%, and 9.5% in the usual care population. Spirometry completion, controller fills, and patients with favorable Asthma Medication Ratios significantly increased for intervention office patient relative to the usual care population.

CONCLUSIONS

A primary care-based asthma clinic was associated with a significant and sustainable reduction in ED utilization versus usual care. What's new: This study describes a comprehensive, multi-disciplinary, and innovative model for an asthma management program within the medical home that demonstrated a significant reduction in ED visits, an increase in spirometry utilization, and an increase in controller fills in a high-risk asthma population versus comparison group.

Are inner-city children with asthma receiving specialty care as recommended in national asthma guidelines?

OBJECTIVE

To examine whether children with asthma in an urban health care network are receiving asthma specialty care, and which factors, if any, are associated with the receipt of this care, including child's racial/ethnic group, age, socio-economic status (SES), insurance, and/or acute care utilization.

METHODS

This study is a retrospective cohort study of children aged 7-17 years who received primary care at an urban medical center in 2012 and had a primary or secondary ICD9 code for asthma. Data on asthma-related health care utilization from 1997 to 2012 were accessed using a software application linked to the electronic medical record. Analyses included descriptive statistics (means and percentages) as well as bivariate and multivariable logistic regressions.

RESULTS

The participants were 4959 children (59% Hispanic and 37% Black, Non-Hispanic) with a mean age = 11.1 years ± 3.05, with 56.8% males. Only 19% of the children had outpatient asthma specialist care: pulmonary (16%) and/or allergy (7%). Only 42% with an asthma-related hospitalization had an outpatient asthma specialist visit. The receipt of specialty care did not vary by race/ethnicity, SES or private vs. public insurance, but was more likely with hospitalization for asthma (OR 3.4) or ≥2 lifetime ED visits (OR 2.6) and less likely for those who were uninsured (OR 0.7).

CONCLUSIONS

In contrast to guideline recommendations, few inner-city children with high asthma morbidity in this sample had seen asthma specialists. Efforts are needed to ensure that inner-city children with asthma are receiving guideline-recommended asthma specialty care.

Spirometry in Asthma Care: A Review of the Trends and Challenges in Pediatric Practice

BACKGROUND

Given the rising incidence of noncommunicable diseases (NCDs) globally, especially bronchial asthma, there is the need to reduce the associated morbidity and mortality by adopting an objective means of diagnosis and monitoring.

AIM

This article aims to review the trends and challenges in the use of spirometry for managing childhood bronchial asthma especially in developing countries.

METHODS

We conducted a literature search of published data on the use of spirometry for the diagnosis of childhood bronchial asthma with special emphasis resource-poor countries.

RESULTS

Guidelines for the diagnosis and treatment of childhood asthma recommend the use of spirometry, but this is currently underused in both tertiary and primary care settings especially in developing countries. Lack of spirometers and proper training in their use and interpretation of findings as well as a dearth of asthma guidelines remains core to the underuse of spirometry in managing children with asthma. Targeting education of health care staff was, however, observed to improve its utility, and practical implementable strategies are highlighted.

CONCLUSIONS

Spirometry is not frequently used for asthma diagnosis in pediatric practice especially in resource-poor countries where the NCD burden is higher. Strategies to overcome the obstacles are implementable and can make a difference in reducing the burden of NCD.

Overdiagnosis of asthma in children in primary care: a retrospective analysis

BACKGROUND

Asthma is one of the most common chronic diseases in childhood. According to guidelines, a diagnosis of asthma should be confirmed using lung function testing in children aged >6 years. Previous studies indicate that asthma in children is probably overdiagnosed. However, the extent has not previously been assessed.

AIM

To assess the extent and characteristics of confirmed and unconfirmed diagnoses of asthma in children who were diagnosed by their GP as having asthma or who were treated as having asthma.

DESIGN AND SETTING

Retrospective analysis in four academic primary healthcare centres in Utrecht, the Netherlands.

METHOD

Routine care registration data of children aged 6-18 years who received a diagnosis of asthma or were treated as having asthma were analysed.

RESULTS

In only 16.1% (n = 105) of the children diagnosed with asthma was the diagnosis confirmed with spirometry, whereas in 23.2% (n = 151) the signs and symptoms did give rise to suspected asthma but the children should have undergone further lung function tests. In more one-half (53.5%, n = 349) of the children the signs and symptoms made asthma unlikely and thus they were most likely overdiagnosed. The remaining 7.2% (n = 47) were probably correctly classified as not having asthma. The main reasons for classifying asthma without children undergoing further lung function tests were dyspnoea (31.9%, n = 174), cough (26.0%, n = 142), and wheezing (10.4%, n = 57).

CONCLUSION

Overdiagnosis of childhood asthma is common in primary care, leading to unnecessary treatment, disease burden, and impact on quality of life. However, only in a small percentage of children is a diagnosis of asthma confirmed by lung function tests.

Clinical Tools to Assess Asthma Control in Children

Asthma affects an estimated 7 million children and causes significant health care and disease burden. The most recent iteration of the National Heart, Lung and Blood Institute asthma guidelines, the Expert Panel Report 3, emphasizes the assessment and monitoring of asthma control in the management of asthma. Asthma control refers to the degree to which the manifestations of asthma are minimized by therapeutic interventions and the goals of therapy are met. Although assessment of asthma severity is used to guide initiation of therapy, monitoring of asthma control helps determine whether therapy should be maintained or adjusted. The nuances of estimation of asthma control include understanding concepts of current impairment and future risk and incorporating their measurement into clinical practice. Impairment is assessed on the basis of frequency and intensity of symptoms, variations in lung function, and limitations of daily activities. "Risk" refers to the likelihood of exacerbations, progressive loss of lung function, or adverse effects from medications. Currently available ambulatory tools to measure asthma control range are subjective measures, such as patient-reported composite asthma control score instruments or objective measures of lung function, airway hyperreactivity, and biomarkers. Because asthma control exhibits short- and long-term variability, health care providers need to be vigilant regarding the fluctuations in the factors that can create discordance between subjective and objective assessment of asthma control. Familiarity with the properties, application, and relative value of these measures will enable health care providers to choose the optimal set of measures that will adhere to national standards of care and ensure delivery of high-quality care customized to their patients.

Effectiveness of the Spirometry 360 Quality Improvement Program for Improving Asthma Care: A Cluster Randomized Trial

OBJECTIVE

To determine the effectiveness of the Spirometry 360 distance learning quality improvement (QI) program for enhancing the processes and outcomes of care for children with asthma.

METHODS

Cluster randomized controlled trial involving 25 matched pairs of pediatric primary care practices. Practices were recruited from 2 practice-based research networks: the Slone Center Office-based Research Network at Boston University, Boston, Mass, and the Puget Sound Pediatric Research Network, Seattle, Wash. Study participants included providers from one of the 50 enrolled pediatric practices and 626 of their patients with asthma. Process measures assessed included spirometry test quality and appropriate prescription of asthma controller medications. Outcome measures included asthma-specific health-related quality of life, and outpatient, emergency department, and inpatient utilization for asthma.

RESULTS

At baseline, 25.4% of spirometry tests performed in control practices and 50.4% of tests performed in intervention practices were of high quality. During the 6-month postintervention period, 28.7% of spirometry tests performed in control practices and 49.9% of tests performed in intervention practices were of high quality. The adjusted difference-of-differences analysis revealed no intervention effect on spirometry test quality. Adjusted differences-of-differences analysis also revealed no intervention effect on appropriate use of controller medications or any of the parent- or patient-reported outcomes examined.

CONCLUSIONS

In this study, the Spirometry 360 distance learning QI program was ineffective in improving spirometry test quality or parent- or patient-reported outcomes. QI programs like the one assessed here may need to focus on practices with lower baseline performance levels or may need to be tailored for those with higher baseline performance.

High-Resolution Time-Frequency Spectrum-Based Lung Function Test from a Smartphone Microphone

In this paper, a smartphone-based lung function test, developed to estimate lung function parameters using a high-resolution time-frequency spectrum from a smartphone built-in microphone is presented. A method of estimation of the forced expiratory volume in 1 s divided by forced vital capacity (FEV₁/FVC) based on the variable frequency complex demodulation method (VFCDM) is first proposed. We evaluated our proposed method on 26 subjects, including 13 healthy subjects and 13 chronic obstructive pulmonary disease (COPD) patients, by comparing with the parameters clinically obtained from pulmonary function tests (PFTs). For the healthy subjects, we found that an absolute error (AE) and a root mean squared error (RMSE) of the FEV₁/FVC ratio were 4.49% ± 3.38% and 5.54%, respectively. For the COPD patients, we found that AE and RMSE from COPD patients were 10.30% ± 10.59% and 14.48%, respectively. For both groups, we compared the results using the continuous wavelet transform (CWT) and short-time Fourier transform (STFT), and found that VFCDM was superior to CWT and STFT. Further, to estimate other parameters, including forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), and peak expiratory flow (PEF), regression analysis was conducted to establish a linear transformation. However, the parameters FVC, FEV1, and PEF had correlation factor r values of 0.323, 0.275, and -0.257, respectively, while FEV₁/FVC had an r value of 0.814. The results obtained suggest that only the FEV1/FVC ratio can be accurately estimated from a smartphone built-in microphone. The other parameters, including FVC, FEV1, and PEF, were subjective and dependent on the subject's familiarization with the test and performance of forced exhalation toward the microphone.

A primary care-based asthma program improves recognition and treatment of persistent asthma in inner-city children compared to routine care

OBJECTIVE

To examine whether a primary care-based asthma program that applies the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-2007 criteria to classify asthma severity increases detection of persistent asthma in inner-city children and affects "step of care" compared to routine care.

METHODS

A retrospective chart review was conducted of 97 consecutive children referred to the asthma program from 2011-2013. Asthma severity documented during routine health care maintenance visits was compared to the asthma severity assessed during the asthma program visit using five standardized questions and spirometry. Medication plan "step of care" was compared pre- and post- the asthma program visit.

RESULTS

79 children, ages 5-19 years old (mean = 9.6), had spirometry tracings meeting American Thoracic Society criteria and were included in this study. 53% were male. The majority of children were Latino (45.6%) or African American (35.4%). At the asthma program visit, more children were identified with moderate or severe persistent asthma based upon clinical questions (47.9%), spirometry (56.9%) or combined criteria (75.3%) than had been identified during routine care (15.2%); all p < .05. After the asthma program visit, more children were prescribed controller medications (82.3% vs 63.3%; p < .05) and 40.6% had their medication plan stepped up.

CONCLUSIONS

In this population of inner-city children, asthma severity was under-recognized and undertreated during routine care. A primary care based asthma program, which formalized applying EPR-3 criteria, increased detection of persistent asthma and led to "step-ups" in treatment plans.

Monitoring asthma in childhood: lung function, bronchial responsiveness and inflammation

This review focuses on the methods available for measuring reversible airways obstruction, bronchial hyperresponsiveness (BHR) and inflammation as hallmarks of asthma, and their role in monitoring children with asthma. Persistent bronchial obstruction may occur in asymptomatic children and is considered a risk factor for severe asthma episodes and is associated with poor asthma outcome. Annual measurement of forced expiratory volume in 1 s using office based spirometry is considered useful. Other lung function measurements including the assessment of BHR may be reserved for children with possible exercise limitations, poor symptom perception and those not responding to their current treatment or with atypical asthma symptoms, and performed on a higher specialty level. To date, for most methods of measuring lung function there are no proper randomised controlled or large longitudinal studies available to establish their role in asthma management in children. Noninvasive biomarkers for monitoring inflammation in children are available, for example the measurement of exhaled nitric oxide fraction, and the assessment of induced sputum cytology or inflammatory mediators in the exhaled breath condensate. However, their role and usefulness in routine clinical practice to monitor and guide therapy remains unclear, and therefore, their use should be reserved for selected cases.

Differences in spirometry values between U.S. children 6-11 years and adolescents 12-19 years with current asthma, 2007-2010

BACKGROUND

National Asthma Education and Prevention Program (NAEPP) guidelines recommend that periodic spirometry be performed in youth with asthma. NAEPP uses different spirometry criteria to define uncontrolled asthma for children (6-11 years) and adolescents (12+ years).

OBJECTIVE

To describe differences in spirometry between U.S. children and adolescents with current asthma.

METHODS

We examined cross-sectional spirometry data from 453 U.S. youth with current asthma age 6-19 years from the 2007-2010 National Health and Nutrition Examination Surveys. The main outcomes were percentage predicted forced expiratory volume at 1 sec (FEV1%) ≤80 and the ratio of FEV1 to forced vital capacity (FEV1/FVC) ≤0.80. We also examined the prevalence of youth with spirometry values consistent with uncontrolled asthma, using NAEPP age-specific criteria, defined for children aged 6-11 years as FEV1% ≤80 or FEV1/FVC ≤0.80, and for adolescents aged 12-19 years as FEV1% ≤80.

RESULTS

Children 6-11 years and adolescents 12-19 years did not differ in prevalence of FEV1% ≤80 (10.1% vs. 9.0%) or FEV1/FVC ≤0.80 (30.6% vs. 29.8%). However, based on the NAEPP age-specific criteria, 33.0% of children 6-11 years and 9.0% of adolescents 12-19 years had spirometry values consistent with uncontrolled asthma (P < 0.001).

CONCLUSION

Children 6-11 years and adolescents 12-19 years with current asthma did not differ in the percentage with FEV1% ≤80 or FEV1/FVC ≤0.80. However, the percent of children and adolescents with spirometry values consistent with uncontrolled asthma did differ. The difference appears to stem mainly from the different spirometry criteria for the two age groups.

Ground zero: not asthma at all

Upper airway obstruction is commonly misdiagnosed as asthma. We report on four children with recurrent respiratory symptoms who had been erroneously diagnosed as having asthma and who received anti-asthma medication for several years. The evaluation of spirometry tracing was neglected in all cases. Subglottic stenosis, tracheomalacia secondary to tracheo-esophageal fistula, double aortic arch, and vocal cord dysfunction were suspected by direct inspection of the flow-volume curves and eventually diagnosed. The value of clinical history and careful evaluation of spirometry tracing in children with persistent respiratory symptoms is critically discussed.

Choosing wisely: adherence by physicians to recommended use of spirometry in the diagnosis and management of adult asthma

PURPOSE

The National Asthma Education and Prevention Program (NAEPP) and the American Thoracic Society provide guidelines stating that physicians should use spirometry in the diagnosis and management of asthma. The aim of this study was to evaluate the trends, over a 10-year period, in the utilization of spirometry in patients newly diagnosed with asthma. We hypothesized that spirometry use would increase in physicians who care for asthma patients, especially since 2007, when the revised NAEPP guidelines were published.

METHODS

This retrospective cohort analysis of spirometry use in subjects newly diagnosed with asthma used a privately insured adult population for the years 2002-2011. Our primary outcome of interest was spirometry performed within a year (± 365 days) of the initial date of asthma diagnosis. We also examined the type of asthma medications prescribed.

RESULTS

In all, 134,208 patients were found to have a diagnosis of asthma. Only 47.6% had spirometry performed within 1 year of diagnosis. Younger patients, males, and those residing in the Northeast were more likely to receive spirometry. Spirometry use began to decline in 2007. Patients cared for by specialists were more likely to receive spirometry than those cared for by primary care physicians; 80.1% vs 23.3%, respectively. Lastly, even without spirometry, a significant portion of patients (78.3%) was prescribed asthma drugs.

CONCLUSIONS

Our study suggests that spirometry is underutilized in newly diagnosed asthma patients. Moreover, the use of controller medications in those diagnosed with asthma without spirometry remains high.

Mismatch between asthma symptoms and spirometry: implications for managing asthma in children

OBJECTIVES

To examine the concordance between spirometry and asthma symptoms in assessing asthma severity and beginning therapy by the general pediatrician.

STUDY DESIGN

Between 2008 and 2012, spirometry testing was satisfactorily performed in 894 children (ages 5-19 years) whose asthma severity had been determined by their pediatrician using asthma guideline-based clinical criteria. Spirometry-determined asthma severity using national asthma guidelines and clinician-determined asthma severity were compared for concordance using weighted Kappa coefficients.

RESULTS

Thirty percent of participants had clinically determined intermittent asthma; 32%, 33%, and 5% had mild, moderate, and severe, persistent asthma, respectively. Increasing disease severity was associated with decreases in the forced expiratory volume in 1 second/forced vital capacity (FVC) ratio (P < .001), the forced expiratory volume in 1 second/FVC% predicted (P < .0001), and the FVC% predicted (P < .01). In 319 children (36%), clinically determined asthma severity was lower than spirometry-determined severity. Concordance was 0.16 (95% CI 0.10, 0.23), and when adjusted for bias and prevalence, was 0.20 (95% CI 0.17, 0.23). When accounting for age, sex, exposure to smoke, and insurance type, only spirometry-determined asthma severity was a significant predictor of agreement (P < .0001), with worse agreement as spirometry-determined severity increased.

CONCLUSIONS

Concordance between spirometry and asthma symptoms in determining asthma severity is low even when guideline-based clinical assessment tools are used. Because appropriate therapy reduces asthma morbidity and is guided by disease severity, results from spirometry testing could better guide pediatricians in determining appropriate therapy for their patients with asthma.

Spirometry use in children hospitalized with asthma

Asthma is the most common chronic disorder of childhood and continues to be a leading cause of pediatric hospital admission. The National Asthma Education and Prevention Program (NAEPP) recommends that spirometry be obtained for asthma patients upon hospital admission, after bronchodilation during the acute phase of asthma symptoms, and at least one additional time before discharge from the hospital. The objectives of this study were to describe the use of spirometry in children hospitalized with asthma and to determine association of pulmonary function with future exacerbations. A retrospective cohort study design was utilized involving review of medical records of children ≥5 years old admitted with asthma to Cincinnati Children's Hospital Medical Center from September 1, 2009 to March 31, 2011. Hospitalization or emergency department (ED) visits were identified by the ICD-9-CM codes of having either a primary diagnosis of asthma (493) or a respiratory illness (460-496) plus a secondary diagnosis of asthma. Asthma re-exacerbation was defined as either having an ED visit or hospitalization for asthma that occurred within 3 months after the index hospitalization. All spirometries were performed in a pediatric pulmonary function laboratory. Among 1,037 admissions included in this study, 89 (8.6%) had spirometry that was recommended by a consulting asthma specialist and usually performed on the day of discharge. Spirometries for forty-five of these patients (54.9%) met all acceptability and repeatability criteria of the American Thoracic Society. Patients who performed acceptable spirometry were significantly older (12.4 ± 3.8 vs. 10.7 ± 3.0 years; P = 0.041). The average forced expiratory volume in the first second (FEV1 ) was 84.4 ± 19.7% predicted; forced vital capacity (FVC) was 98.1 ± 16.0% predicted; FEV1 /FVC was 74.6 ± 9.6%; forced expiratory flow at 25-75% (FEF25-75 ) was 61.2 ± 30.1% predicted. Ten patients (22%) who performed spirometry developed a re-exacerbation. Patients with versus without re-exacerbation had significantly lower FEV1 /FVC (P = 0.027) and FEF25-75 (P = 0.031). Nevertheless, separate logistic regression models found that FEV1 /FVC and FEF25-75 were not associated with re-exacerbation when adjusted for age and length-of-stay. We found that few children admitted with asthma had spirometry as recommended in the NAEPP guidelines unless recommended by specialists and both lower lung function (FEV1 /FVC and FEF25-75 ) and history of more frequent and more recent prior health-care utilization for asthma were associated with repeat asthma exacerbation. However, the value of performing spirometry on asthmatic children prior to hospital discharge remains unclear and will require prospective study.

Characterizing asthma from a drop of blood using neutrophil chemotaxis

Asthma is a chronic inflammatory disorder that affects more than 300 million people worldwide. Asthma management would benefit from additional tools that establish biomarkers to identify phenotypes of asthma. We present a microfluidic solution that discriminates asthma from allergic rhinitis based on a patient's neutrophil chemotactic function. The handheld diagnostic device sorts neutrophils from whole blood within 5 min, and generates a gradient of chemoattractant in the microchannels by placing a lid with chemoattractant onto the base of the device. This technology was used in a clinical setting to assay 34 asthmatic (n = 23) and nonasthmatic, allergic rhinitis (n = 11) patients to establish domains for asthma diagnosis based on neutrophil chemotaxis. We determined that neutrophils from asthmatic patients migrate significantly more slowly toward the chemoattractant compared with nonasthmatic patients (P = 0.002). Analysis of the receiver operator characteristics of the patient data revealed that using a chemotaxis velocity of 1.55 μm/min for asthma yields a diagnostic sensitivity and specificity of 96% and 73%, respectively. This study identifies neutrophil chemotaxis velocity as a potential biomarker for asthma, and we demonstrate a microfluidic technology that was used in a clinical setting to perform these measurements.

Spirometry in children

Respiratory disorders are responsible for considerable morbidity and mortality in children. Spirometry is a useful investigation for diagnosing and monitoring a variety of paediatric respiratory diseases, but it is underused by primary care physicians and paediatricians treating children with respiratory disease. We now have a better understanding of respiratory physiology in children, and newer computerised spirometry equipment is available with updated regional reference values for the paediatric age group. This review evaluates the current literature for indications, test procedures, quality assessment, and interpretation of spirometry results in children. Spirometry may be useful for asthma, cystic fibrosis, congenital or acquired airway malformations and many other respiratory diseases in children. The technique for performing spirometry in children is crucial and is discussed in detail. Most children, including preschool children, can perform acceptable spirometry. Steps for interpreting spirometry results include identification of common errors during the test by applying acceptability and repeatability criteria and then comparing test parameters with reference standards. Spirometry results depict only the pattern of ventilation, which may be normal, obstructive, restrictive, or mixed. The diagnosis should be based on both clinical features and spirometry results. There is a need to encourage primary care physicians and paediatricians treating respiratory diseases in children to use spirometry after adequate training.

Primary care physicians' knowledge of and confidence in their referrals for special education services in 3- to 5-year-old children

BACKGROUND

Children 3 to 5 years old with developmental delays are eligible for special education services.

OBJECTIVE

To assess primary care physicians' (PCPs) knowledge, attitudes, and practices regarding their referrals to the special education system on behalf of children 3 to 5 years old.

DESIGN/METHODS

Mail survey of 400 office-based general pediatricians and 414 family physicians in Michigan, fielded in fall 2012 and winter 2013, with a response rate of 44%. The 4-page survey included knowledge questions about special education eligibility, PCPs' role in accessing school-based services, and self-confidence in ability to help patients access these services.

RESULTS

PCPs neither fully understood requirements for special education services nor were they very confident in identifying 3- to 5-year-old children eligible for special education services.

CONCLUSIONS

PCPs recognize interacting with special education as a relative weakness, and they may be accepting of interventions to improve their knowledge and skills.

Spirometry in primary care: an analysis of spirometery test quality in a regional primary care asthma program

BACKGROUND

Primary care office spirometry can improve access to testing and concordance between clinical practice and asthma guidelines. Compliance with test quality standards is essential to implementation.

OBJECTIVE

To evaluate the quality of spirometry performed onsite in a regional primary care asthma program (RAP) by health care professionals with limited training.

METHODS

Asthma educators were trained to perform spirometry during two 2 h workshops and supervised during up to six patient encounters. Quality was analyzed using American Thoracic Society (ATS) 1994 and ATS⁄European Respiratory Society (ERS) 2003 (ATS⁄ERS) standards. These results were compared with two regional reference sites: a primary care group practice (Family Medical Centre [FMC], Windsor, Ontario) and a teaching hospital pulmonary function laboratory (London Health Sciences Centre [LHSC], London, Ontario).

RESULTS

A total of 12,815 flow-volume loops (FVL) were evaluated: RAP - 1606 FVL in 472 patient sessions; reference sites - FMC 4013 FVL in 573 sessions; and LHSC - 7196 in 1151 sessions. RAP: There were three acceptable FVL in 392 of 472 (83%) sessions, two reproducible FVL according to ATS criteria in 428 of 469 (91%) sessions, and 395 of 469 (84%) according to ATS⁄ERS criteria. All quality criteria - minimum of three acceptable and two reproducible FVL according to ATS criteria in 361 of 472 (77%) sessions and according to ATS⁄ERS criteria in 337 of 472 (71%) sessions. RAP met ATS criteria more often than the FMC (388 of 573 [68%]); however, less often than LHSC (1050 of 1151 [91%]; P<0.001).

CONCLUSIONS

Health care providers with limited training and experience operating within a simple quality program achieved ATS⁄ERS quality spirometry in the majority of sessions in a primary care setting. The quality performance approached pulmonary function laboratory standards.